|Year : 2016 | Volume
| Issue : 3 | Page : 178-185
Mass gatherings: A one-stop opportunity to complement global disease surveillance
Habida Elachola1, Ernesto Gozzer2, Jiatong Zhuo3, Samba Sow4, Rana F Kattan5, Samara A Mimesh6, Jaffar A Al-Tawfiq7, Mohammed Al-Sultan8, Ziad A Memish9
1 Atlanta, Georgia, USA
2 Department of Medicine, Instituto Nacional de Salud, Lima, Peru, China
3 Guangxi Centers for Disease Control and Prevention, Guangxi, China
4 Director, Center for Vaccine Development, Vaccine Research Institute, Bamako, Mali, Saudi Arabia
5 Department of Paediatric, King Abdullah Specialist Children's Hospital, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
6 Department of Medicine, King Fahad Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
7 Department of Speciality Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
8 Assistant Secretary General of Postgraduate Studies, Saudi Commission for Health Specialties, Riyadh, Saudi Arabia
9 Ministry of Health; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
|Date of Web Publication||18-Jul-2016|
Atlanta, Georgia, USA
Emerging infections including those resulting from the bioterrorist use of infectious agents have indicated the need for global health surveillance. This paper reviews multiple surveillance opportunities presented by mass gatherings (MGs) that align with fundamental questions in epidemiology (why, what, who, where, when and how). Some MGs bring together large, diverse population groups coming from countries with high prevalence of communicable diseases and disparate surveillance capacities. MGs have the potential to exacerbate the transmission dynamics of infectious diseases due to various factors including the high population density and rigor of events, increase in number of people with underlying diseases that predisposes them to disease acquisition, mixing of people from countries or regions with and without efficient disease control efforts, and varying endemicity or existence of communicable diseases in home countries. MGs also have the potential to increase the opportunities for mechanical and even heat-related injuries, morbidity or deaths from accidents, alcohol use, deliberate terrorist attacks with biological agents and/or with explosives and from exacerbation of pre-existing conditions. Responding to these wider range of events may require the use of novel bio-surveillance systems designed to collect data from different sources including electronic and non-electronic medical records from emergency departments and hospitalisations, laboratories, medical examiners, emergency call centres, veterinary, food processors, drinking water systems and even other non-traditional sources such as over-the-counter drug sales and crowd photographs. Well-structured, interoperable real-time surveillance and reporting systems should be integral to MG planning. The increase in magnitude of participants exceeding millions and diversity of people attending MGs can be proactively used to conduct active surveillance of communicable and non-communicable diseases or indicators of global and national public health interest during MGs than can collectively complement efforts to enhance global health security.
Keywords: Epidemiology, global health surveillance, mass gathering
|How to cite this article:|
Elachola H, Gozzer E, Zhuo J, Sow S, Kattan RF, Mimesh SA, Al-Tawfiq JA, Al-Sultan M, Memish ZA. Mass gatherings: A one-stop opportunity to complement global disease surveillance. J Health Spec 2016;4:178-85
|How to cite this URL:|
Elachola H, Gozzer E, Zhuo J, Sow S, Kattan RF, Mimesh SA, Al-Tawfiq JA, Al-Sultan M, Memish ZA. Mass gatherings: A one-stop opportunity to complement global disease surveillance. J Health Spec [serial online] 2016 [cited 2020 Jun 6];4:178-85. Available from: http://www.thejhs.org/text.asp?2016/4/3/178/186487
| Introduction|| |
The emerging epidemics and biological events of the last few decades have alerted the global public health community on the importance of global health surveillance. The bioterrorist use of anthrax spores in 2001, the emergence of the Middle East respiratory syndrome (MERS), and the 4 WHO declared Public Health Emergency of International Concern (PHEICs)(2003 severe acute respiratory syndrome [SARS] outbreak, the 2009 pandemic influenza A H1N1, the 2014-2015 West Africa Ebola epidemic and, the 2016 Zika virus outbreak) are key events that elevated the collective interest in public health surveillance as a tool to identify, prevent and control emerging and/or reemerging diseases globally. ,,, Despite this awareness, currently, no global surveillance systems exist that provide a one-stop opportunity and sampling frame to conduct surveillance of people from multiple countries. For now, individual countries are responsible for surveillance of emerging diseases. Unfortunately, most of these individual systems, especially in developing countries are suboptimal. Therefore, current global surveillance is only as good as the surveillance capacity in any one country of the world. Although the 2005 International Health Regulations (http://www.who.int/topics/international_health_regulations/en/), an international legal instrument that binds 196 countries established by the WHO, aim to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide, there is a lack of a standard platform to conduct global surveillance to achieve those goals. In this article, we propose a complementary opportunity for global public health surveillance-mass gatherings (MGs) as a surveillance platform.
Although some researchers define MGs as preplanned public events held for a limited period and attended by >25,000 people, some of these events occur spontaneously like those observed in the Middle East during the Arab spring of 2010. , MGs have the potential to exacerbate the outcome of emerging disease threats as they strain the planning and response resources of the community, city, or nation hosting the event. , MGs may be planned or spontaneous. They have largely been a concern for authorities or interest groups dealing with security and amenity planning such as transportation, housing and food supply and the concept of MGs as a public surveillance opportunity has been far removed from global surveillance discussions.
| Why use mass gatherings as a surveillance venue|| |
Although there have been reports of passive surveillance at MGs such as the Federation Internationale de Football Association (FIFA), Olympics Games, Rio and other carnivals, Pope's visits and the Hajj, it was the 2009 pandemic H1N1 influenza that coincided with the 2009 Hajj MG that propelled public health interest in MGs. ,,,, The WHO communique at the 67 th World Health Assembly consolidated these concepts.  The increase in magnitude such as the Kumbh Mela in India that gathers between 70 to 120 million pilgrims and diversity of people attending MGs (almost 180 countries represented in some international MGs such as the Hajj), ,,, and lack of other robust opportunities to conduct surveillance of the global population, makes MGs a venue for active surveillance of disease conditions or indicators of interest at global, national and/or select population levels.
Thus, the most important aspects of MGs that relates to surveillance is the ease of access to diverse (often international) population groups from various geographic locations congregated in a single venue in a specific time frame. There are indeed many other characteristics of MGs that favour surveillance.
First, is the challenge of global monitoring of emerging infectious disease threats. Due to the extreme variation in disease surveillance, control strategies and availability of resources among home countries of participants in MGs, there is no strategy in place to predict what condition and/or circulating pathogen may find appropriate environment for occurrence or transmission during a MG. ,, If a disease emerges in any one country that participates in a MG, travel and trade activities increase mixing of MGs participants with the global community, no country is safe from MG-related disease transmission. Pre-planned MGs present public health practitioners a moving target and demand constant preparedness as they affect the host country as well as those of the participants. For example, contact humans with animals or animal sacrifices are integral to some MGs (religious events or festivals) and are of concern for zoonotic disease transmission. 
Second, MG attendees are at increased risk for disease acquisition or transmission. When compared to the general population, the risk of adverse public health events among MG attendees are greater due to the lack of social distancing, high population density (e.g., airborne diseases), mixing of susceptible (e.g., unvaccinated) or immunocompromised persons with potential carriers of infections, rituals or activities that increases disease transmission opportunities, unexpected extremes of weather, and demand for facilities exceeding establishment leading to mass injuries and deaths. ,,,,, These predisposing factors and event-specific attributes have highlighted the importance of passive surveillance at MGs that help to predict and prepare for adverse infectious disease outcomes.
Third, is the information need created by increased awareness of geopolitical significance of health and security events during MG. ,,,, Much of the interest in MGs has been due to its impact on disease transmission or event-related adverse health outcomes that gain visibility in media. Currently, most MG based surveillance programs are confined to infectious disease agents with high transmission potential. MGs may serve as a potential venue for deliberate release of biological and chemical agents. Incidences such as the terrorist attacks during the 1972, 1976, and the 1996 Olympics and 2013 Boston Marathon, and the stampede-related deaths during the 2015 Hajj, became events of immense media and political relevance and there is huge demand for information on health impact.
Finally, the opportunities and needs for surveillance during MG are emerging. The existence of established contacts with the healthcare delivery system and widely available medical infrastructure associated with MGs provide sampling venue and sampling frame. In recent times, there has also been an increasing trend in people with non-communicable disease taking part in MGs that increases their risk of acquiring communicable disease. For some population groups with sufficient representation (such as the Hindu population of India attending the Kumba Mela MG),  MGs provide an opportunity for active surveillance. Medical examinations, vaccinations and participant education programmes are now mandatory for participation in some MGs. , Innovative rapid testing laboratory capacities, technological advances in data collection and electronic data on transportation and movements of people available for ticketed or visa controlled events are opportunities for surveillance. ,,,,,,, Because MG participants congregate in a specific geographic location and the timing is predictable, it is possible to avoid the usual logistical challenges of systematic surveillance attempts of reaching widely dispersed population and reduce the duration of data collection. Because most MGs are of a defined duration and often short, all data gathering activities need to be completed in that time frame. Other advantage points include an access to demographic information that can inform the sampling procedures and designated arrival and departure information allowing for case-control and prospective studies. ,,,,
Surveillance, when linked to policy and planning units of MGs, improves the efficiency and effectiveness of preparedness. Infectious diseases are not the only threats facing MGs. ,,
Some MGs such as music and sports events may facilitate social and behavioural risk factors such as drug abuse, unsafe sexual behaviours, and violent conflicts among participants. Injuries and fatalities can result from structural damage to buildings, fire, traffic accidents, stampede and terrorist attacks. Therefore, surveillance systems can be designed and implemented to prepare for varying public health challenges.
| What types of data can be obtained during mass gatherings?|| |
Routine case reporting at mass gatherings
Clinical facilities operating in MG venues are critical for surveillance. In the absence of active surveillance methods, documentation and reporting of consultations and admissions in such facilities may be the only source of data. All MGs make provisions for some level of medical care. Major established religious and sports events such as the Hajj, FIFA and Olympics Games have emergency clinical facilities on site and liaise with regional medical facilities for advanced care. To the best of our knowledge, the Hajj is the only MG with a well-established healthcare delivery system that ranges from primary care to fully equipped tertiary care hospitals offering specialised care including intensive care units. 
Reporting of significant event outcomes (accidents, outbreaks and natural calamities)
Large outbreaks of infectious diseases, injuries, illness and deaths from natural calamities, accidents and deliberate actions can occur during MGs. Examples include the Boston Marathon bomb attacks in 2013, stampede related deaths during the 2015 Hajj, and Influenza outbreak at World Youth Day in Australia in 2008. ,, Because of the high volume of cases, reporting of such events may not be feasible through the routine clinical case reporting system, and simplified tools may be necessary. Event based surveillance using internet media search engines, specialized media and social networking sites can provide the first alerts. ,,,,
Monitoring health protection behaviours
Several standard interviewer-administered surveys, and indirect (observational) assessments of participants' compliance with health advisories including the use of crowd photographs were conducted during the Hajj. ,,, With the advent of hand-held devices they can be done with much ease now, compared to the paper-pencil method.
Medical risk factor monitoring
Information on existing medical conditions and risk avoidance behaviours are important to determine population at risk for certain outcomes and to plan for medical care needs during MG events. ,,, Such baseline data collection can be conducted during pre-departure medical examinations. Such active and systematic case finding and monitoring activities can provide information on health events that can compromise a person's participation in MG events, or those incur high financial and logistical burden on the participants, and organisations or governments. In case of outbreaks or health events that require retrospective information, data from both of these types of surveys can provide baseline information for outbreak and cohort studies. Departure and arrival screening at airports became a routine practice in the aftermath of SARS, and recently during the 2014 Ebola crisis, and such practices can be expanded or modified to increase the relevancy of information collected. ,,
Enhanced surveillance for diseases of global concern
International MGs provide the opportunity to surveys for specific diseases of global relevance or epidemic potential including those with laboratory components. ,, There may be a list of routine conditions or syndromes required during all events (such as surveillance for various influenza strains), or conditions recommended by the Global Health Security Agenda). Ad hoc conditions added depending on its current or emerging importance (for example MERS coronavirus, Zika virus) or exposure history obtainable from serology testing.
General health surveys
If the MG participants from a given country, or demographic group is large enough and representative of respective population groups, other active surveillance on general health conditions or risk factors including smoking, cholesterol levels, blood pressure, eye examinations can be conducted at relatively lower cost than other sources of such data such as the national surveys. Such activities are of relevance to countries that lack national surveys, or if available data on specific subgroups such as minorities are inadequate to inform policies.
Laboratory analysis of biological specimens collected from MG participants is a routine practice in healthcare facilities used by MG participants and provide surveillance data. Laboratory specimens may be collected, especially for surveillance and research purposes alone or as part of other comprehensive surveillance systems. ,
| When to conduct mg surveillance?|| |
International MGs generally include preparatory phase when participants obtain medical clearances and vaccinations or receive seminars on general health matters while they are still in their home countries. Departure airport based health screenings also provide opportunities for brief data collection activities. Baseline surveys of history of exposure to certain disease agents (serology) of MG support personnel including health workers can be conducted at this time, and can be compared to post-event data. 
This includes the time from arrival of participants in host country or city to participation in key events and to their departure from the host country or city. This is the most critical period and provide opportunity to assess compliance with disease control strategies, monitor outbreaks, and conduct studies of group behavior related to health outcomes.
Arrival in home countries (or regions if the event is not international) and a defined period of time after arrival. This period will be critical to monitor signs and symptoms of acquisition of any transmissible diseases at the event and to study other effects of MGs on participants. Post-event serological surveillance of health workers to monitor potential exposure is conducted at this phase.
| Where to conduct surveillance during mass gathering?|| |
Home countries/administrative regions of residence of mass gathering participants
Three types of surveillance venues may be feasible in home countries of MG participants that can inform global disease detection initiatives, national health planning and national health security. They include (1) health facilities that provide mandatory medical services such as immunisations, (2) preparatory pre-departure seminars or information sessions offered to MG participants and preparatory training provided to staff who support MG events including health workers and (3) ports serving as departure and arrival points. Some organized international MGs require participants to attend pre-departure educational programmes, comply with specific vaccination requirements or preventive practices for obtaining travel approvals, visas or entry to events. For example, Mali mandated hand washing with 1% chlorine solution and temperature monitoring of each of the participants entering through over 150 secured gates to the Mauloud MG venue held during the 2014-2015 Ebola crisis. The Hajj visa requirements include meningitis and polio vaccinations certificates. Such contacts of MG participants with the healthcare system in their respective home countries can be proactively utilised as a surveillance opportunity; and in some countries, the only surveillance opportunity to access a huge survey sample.
Host country/venues of mass gatherings
The relevance of ports as venues for surveillance is high if the MG is international. This is because of the ease of access to administer surveillance activities as border control procedures often involve public health monitoring and/or intervention activities, the ability to monitor importation and exportation of communicable diseases, the ease of categorisation for cohort or exposure (to threats or interventions such as vaccines) studies, the ease of sampling procedures as some demographic information may be available, and office space or administrative space may be more easily available than at a MG venue. Various observational and cohort studies including collection of nasopharyngeal swabs have been conducted at the Hajj. ,
Mass gathering event venues
Opportunities for surveillance at MG event venues vary depending on the type and duration of the gathering, population concentration at events, and type of accommodation used by participants. Surveys and observational studies can be conducted at event venues. MGs that provide accommodation in tents may be more easily accessible than hotel based accommodation that are more dispersed. Surveillance techniques have been used at the Hajj such as serial crowd photographs to assess compliance with prevention advisories including the prevalence of umbrella use for sun protection and face masks to prevent airborne transmission of respiratory diseases at the Hajj during the 2009 pandemic influenza A H1N1 and 2013 MERS-CoV. ,
Event specific clinical facilities (or clinical facilities frequented by MG participants) are the most critical surveillance venues that provide real-time information on disease threats of epidemic potential.  Systems should be set up to record information on all consultations including basic demographics, contact information, symptomatology and diagnosis. Use of electronic data entry system, as opposed to paper based system, will help real-time reporting and trend monitoring. While the reporting of mandatory reportable diseases will follow established protocols for the country or jurisdiction, other diseases may be reported as diagnosed or can be summarised as syndromes. These details of reporting of non-mandatory reportable conditions will depend on standards available in the country or jurisdiction. However, with adequate planning and full utilisation of technological options including electronic medical information systems, select variables of interest such as, age, gender and diagnosis can be made available live to the control room or emergency operations centre.
Commercial pharmaceutical outlets operational around MG venues may be invited to contribute to surveillance by reporting changes in sales volume of medicines and other products such as face masks and alcohol sanitisers. Although no example of such use has been reported in the published literature, one example emerged from Mali in January 2015 when that country held a traditional MG of over 50,000 participants at the time of an on-going Ebola epidemic. Anecdotal reports indicated that pharmaceutical outlets reported very low sales volume of anti-diarrhoeal medications during the 2014-2015 event because of the implementation of mandatory handwashing using chlorinated water provided at more than 150 entrance checkpoints to the venue.
| Who are the targets of surveillance?|| |
The participants of MGs are the main target group for surveillance.
Mass gatherings support personnel
They include health workers, personal grooming service providers, and animal handlers. People who have significantly high number of direct contact with MG participants include health workers, personal grooming service providers (barber shops) and sex workers. Pre- and post-MG event bio-behavioural surveillance of such personnel would be critical to understand modes of transmission of infectious diseases. Shaving of scalp hair is a practice during both Hindu (Kumba Mela) and Muslim rituals (Hajj) and may be often conducted by un-licensed barbers using unsterile instruments.  Pre- and post-event laboratory based surveillance of animal handlers and butchers at the Hajj to assess the animal-human transmission of zoonotic diseases.
To the best of our knowledge, Hajj is the only event that involves animal sacrifice. However, animal sacrifice at the Hajj is now regulated and sacrifice is conducted in automated slaughterhouses by licensed butchers and Hajj pilgrims have no direct contact with sacrificial animals or by products.  Zoonotic disease surveillance conducted among sacrificial animal population include MERS surveillance among animals sacrificed during the Hajj. The Pushkar Camel Festival of India and large livestock markets in Tanzania and Mali bring together huge number of animals and visitors. Surveillance of zoonotic diseases should be a priority in such settings.
| How to plan a surveillance system during a mass gathering|| |
Domestic and international MGs poses different coordination challenges. For domestic MGs, generally the local or national ministry of health would be the most relevant authority to coordinate surveillance. For international MGs, given the various phases of surveillance, no single entity may be responsible for surveillance at all phases, yet coordination among all responsible entities will be critical. For international MGs, national health ministries of home-and host-countries would have a lead role to play and with significant coordination by multinational stakeholders and technical input from relevant international technical bodies or institutions.
For small scale MGs mostly involving citizens of a single country, the responsibility to engage the MG leadership will largely rely on the stewardship and forward thinking of health authorities in respective jurisdictions.
For international MG, surveillance provides an opportunity to foster partnerships in global surveillance. However this is a relatively new concept and leadership is the most critical requirements for transitioning the current state of MG based surveillance from a sporadic activity to a structured and coordinated activity. , First and foremost, planners of MG should include surveillance as a critical element of MG management. Because MG related surveillance initiatives are not part of the health budget of any single country, financing, management and organisation of surveillance activities will need a coordination group that draws resources and support from multiple countries or stakeholder institutions. Because no single country may be responsible for staffing of MG surveillance systems, advance planning would be needed to access staff from multiple countries and stake holder institutions. Laboratory specimen processing may require venue based support for those tests that require immediate access to laboratories and shipping opportunities to alternate laboratories in-country or in other countries. Major MG events have already incorporated some elements of surveillance to the planning. Coordination by stakeholders in public health and global health can complement such foundational opportunities prevalent among established MGs with advanced surveillance concepts, protocols and initiatives.
| Limitations and challenges of mass gathering based surveillance systems|| |
Representativeness is variable
The significance of representativeness is variable depending on what is being measured. Representativeness is not significant when the objective is to detect emerging diseases, or diseases of international significance such as MERS-CoV or Ebola virus disease, than the measurement of indicators and risk factors such as the prevalence of smoking, hypercholesterolemia, or anaemia levels in a target population. Each MG is unique, and country/geographic representativeness may vary significantly. MG may comprise representative participants from some sociodemographic groups or countries (usually the host country) or very few participants from another demographic group or countries. For example, the participants at the Brazilian Carnival (Rio de Janeiro - February-March) despite its international appeal, may be representative of the domestic population but not of other countries.
Robust and advance planning is critical
Given the brevity of most MGs, and there is no second chance to change sample size or mode of data collection, rigorous planning and redundancy plans should be prepared in advance.
Ethical approvals may be complex
In general, surveillance activities are not considered research and are exempt from ethical reviews. However, perceptions and understanding of what is deemed research and public health function may vary, especially if multiple country systems are included. While evaluating adherence of participants to vaccine requirements may be familiar collection of new information, it may be viewed differently. Consultation with relevant stakeholders to establish norms and communication of such efforts would be required.
Participant response may vary
Given that people who attend MG are pre-occupied with the objectives of their mission, their responsiveness and compliance with some activities may be limited. MG community engagement can help improve participant compliance.
Safety of staff
Violence can erupt during MG.  Surveillance staff may be exposed to intentional violent activities such as the Boston Marathon bombing incident in 2013, and accidents such as the stampede during the 2015 Hajj.
| Conclusions|| |
Good public health preparedness framework will require a good public health surveillance system. The value of and opportunities for disease surveillance during MG has not been fully articulated. MG provide an unprecedented opportunity to fill the gaps in global data needs on emerging disease threats and in national health information needs. With access to diverse population groups from multiple geographical regions and catchment areas, several MGs provide a one-stop surveillance opportunity for several emerging diseases. For countries with domestic MGs, MGs may provide low cost surveillance opportunities to fill gaps in general health surveillance. Sufficient international stewardship, collaboration, advanced planning and risk communication would be required to make MG surveillance attempts successful and useful.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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||Urinary tract infection attributed to Escherichia coli isolated from participants attending an unorganized gathering
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||Polio priority countries and the 2018 Hajj: Leveraging an opportunity
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| ||Travel Medicine and Infectious Disease. 2018; |
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||Implications of converging conflicts, emergencies, and mass gatherings for global health security
| ||Habida Elachola,Seydou Doumbia,Rana F Kattan,Ibrahim Abubakar,Ziad A Memish |
| ||The Lancet Global Health. 2018; 6(8): e834 |
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||From Hajj services to Mass Gathering Medicine: Saudi Arabia formalizes a novel discipline
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